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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275200333
Report Date: 02/02/2022
Date Signed: 02/03/2022 10:16:11 AM

Document Has Been Signed on 02/03/2022 10:16 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:MANTE BOARD & CARE HOMEFACILITY NUMBER:
275200333
ADMINISTRATOR:SAMSON Z. MANTEFACILITY TYPE:
735
ADDRESS:1553 CUPERTINO WAYTELEPHONE:
(831) 229-4819
CITY:SALINASSTATE: CAZIP CODE:
93906
CAPACITY: 6CENSUS: 3DATE:
02/02/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Julia ManteTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Steve Chang, Licensing Program Manager (LPM) Romeo Manzano, and Program Clinical Consultant (PCC) Toni Rivera conducted Technical Assistant - PCC through tele-inspection (Zoom),and met with Administrator (ADM) Julia Mante.

The purpose of this TA PCC Tele visit was to review the facility COVID-19 infection mitigation plan and conducted inspection of the facility to ensure plan is being carried out and to provide support and guidance to staff in mitigating the spread of virus.

During tele-visit inspection, a tour of the facility was conducted which started at the main entrance to check COVID-19 signage and screening procedures. The facility has the COVID-19 posters at the main entrance including screening questionnaire forms, hand sanitizer, face masks, thermometer, glove, and a visitor log book at the screening station.

The facility common areas were inspected such as the kitchen, living room, family room, dinning area, bathrooms were observed. There are 5 resident bedrooms, 2 bathrooms in facility. Trash cans were observed with covers. Paper towels with holders, and washing hands signs by the sinks were observed. Cloth towels were observed in the restroom. The laundry room was observed and inspected. ADM stated the meals were provided at bedrooms. ADM stated all the residents and staff are fully vaccinated and done with booster shots.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: MANTE BOARD & CARE HOME
FACILITY NUMBER: 275200333
VISIT DATE: 02/02/2022
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Based on today's inspection, the facility is being recommended the following:

1. Facility was provided a copy of simplified screening questionnaires by PCC to be posted in the main entrance of the facility.
2. Facility to frequently wipe and disinfect high touch areas, it is recommend to use EPA approve (Environmental Protection Agency) disinfection products..
3. Facility to check/monitor body temperature at least 3 times per day for residents and staff.
4. Facility should not use common towels in bathrooms and kitchen due to contamination.
5. Facility to conduct staff training at least monthly or frequently such as donning and doffing PPE and COVID -19 updates.
6. Facility use of N95 mask by staff must have completed a N95 mask fitting test conducted by medical professional per CalOSHA not by CCLD.
7. Facility to have a laundry hamper inside the positive resident’s room, laundry hamper should have a double trash bag.
8. Facility to ensure adequate staffing particularly during COVID-19 outbreak, and to submit LIC500 to CCL.
10. Facility to contact CCLD, SARC and local health department for new positive case(s).
11. Facility to review PINs (Providers’ Information Notification) through CCLD website: www.ccld.ca.gov


Exit interview conducted with Administrator.
A copy of this report was emailed to ADM for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022
LIC809 (FAS) - (06/04)
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